Mental health care (outpatient)
How often is it covered?
Medicare Part B (Medical Insurance) covers mental health services and visits with these types of health professionals:
- Psychiatrist or other doctor
- Clinical psychologist
- Clinical social worker
- Clinical nurse specialist
- Nurse practitioner
- Physician assistant
Part B covers outpatient mental health services, including services that are usually provided outside a hospital, like in these settings:
- A doctor’s or other health care provider’s office
- A hospital outpatient department
- A community mental health center
Part B also covers outpatient mental health services for treatment of inappropriate alcohol and drug use.
Part B helps pay for these covered outpatient services:
- One depression screening per year. The screening must be done in a primary care doctor’s office or primary care clinic that can provide follow-up treatment and referrals.
- Individual and group psychotherapy with doctors or certain other licensed professionals allowed by the state where you get the services.
- Family counseling, if the main purpose is to help with your treatment.
- Testing to find out if you’re getting the services you need and if your current treatment is helping you.
- Psychiatric evaluation.
- Medication management.
- Certain prescription drugs that aren’t usually “self administered”(drugs you would normally take on your own), like some injections.
- Diagnostic tests.
- Partial hospitalization.
- A one-time “Welcome to Medicare” preventive visit. This visit includes a review of your potential risk factors for depression.
- A yearly “Wellness” visit. This is a good time to talk to your doctor or other health care provider about changes in your mental health so they can evaluate your changes year to year.
Your costs in Original Medicare
- You pay nothing for your yearly depression screening if your doctor or health care provider accepts assignment.
- 20% of the Medicare-approved amount for visits to a doctor or other health care provider to diagnose or treat your condition. The Part B deductible applies.
- If you get your services in a hospital outpatient clinic or hospital outpatient department, you may have to pay an additional copayment or coinsurance amount to the hospital. Copied from Medicare.Gov
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Behavioral health integration services
If you have a behavioral health condition (like depression, anxiety, or another behavioral health condition), Medicare may pay for a health care provider’s help to manage that condition if your provider offers the Psychiatric Collaborative Care Model.
is a set of integrated behavioral health services that includes care management support if you have a behavioral health condition. This care management support may include care planning for
- behavioral health conditions,
- ongoing assessment of your condition,
- medication support,
- or other treatments that your provider recommends.
Your health care provider will ask you to sign an agreement for you to get this set of services on a monthly basis. You pay a monthly fee, and the Part B deductible and coinsurance apply.
This article is intended for physicians, providers and suppliers submitting claims to Medicare contractors (carriers and/or Part A/B Medicare Administrative Contractors (A/B MACs) for mental health services provided to Medicare beneficiaries.
The Social Security Act (Section 1862(a)(1)(A)) excludes from coverage services that are not “reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.”
This booklet gives the following Medicare mental health services information:
Covered and non-covered mental health services
- Eligible professionals
- Eligible professionals commonly used Current Procedural Terminology (CPT) codes
- National Correct Coding Initiative (NCCI)
- Provider charts
- Outpatient psychiatric hospital services
- Family psychotherapy (with the patient present and their treatment is the primary purpose) or (without the patient present, is medically reasonable and necessary, and their treatment is the primary purpose)
- Individual and group psychotherapy (individual therapy with one or more therapists and more than one individual in a therapy session with one or more therapists)
- Psychoanalysis (therapy that treats mental disorders by investigating the interaction of conscious and unconscious elements)
- Partial Hospitalization Program (PHP)
- Community Mental Health Centers (CMHC)
- Behavioral Health Integration (BHI) services
- Inpatient Psychiatric Facility (IPF) services
- Medical records requirements
- Coverage period
- Same day billing guidelines
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